ࡱ> '` i1bjbj 4")Fl4HHHHHH8HTH,R J J"J"J"J"J"J"JQQQQQQQ$Rh1UQ"J"J"J"J"JQ"J"JQLLL"J4"J"JQL"JQLLL"JJ W5HHVJLLQ0RLUKULUL<"J"JL"J"J"J"J"JQQL"J"J"JR"J"J"J"J)dCdCd(@h Child Developmental History Questionnaire This questionnaire has been prepared to allow review of your childs development in a variety of areas. Please take the time to complete each of the following pages as thoroughly as possible, and feel free to add your comments and elaborations on additional sheets. Thank you, in advance, for your time and effort with this form. DEMOGRAPHICS Childs full name: ______________________________ Date of Birth: ___________________ Present primary address: Phone number: ( ) Person completing this form: Relation to child: This child is presently in _____ grade Has this child ever been in psychotherapy before? YES NO If YES, please describe: This childs response upon learning that s/he would be meeting with a psychologist was: No way! Im not going! Ill give it a try Child requested services O.K, If I have to ... Child doesnt know yet Reason for Referral Please briefly state the reason this child has been referred for psychological services: Please indicate below which of the following are concerns about this child. Do not mark items that are not of concern. Indicate severity of concern as follows: 1= MOST SEVERE and IMPORTANT 2= LESS SEVERE 3= PROBLEMS, BUT NOT SEVERE a. TOILETING: Bedwetting, Soiling, Smearing, Regressed to Diapers, Constipation b. EATING: Refuses to Eat, Compulsion to Eat, Picky Eater, Vomiting/Purging, Obesity c. SLEEPING: Difficulties Falling Asleep, Night Waking, Apnea, Sleep-Walking, Terrors d. ATTENTION: Inattention, Distractible, Cant Concentrate e. AGGRESSION: Fighting/Bullying, Setting Fires, Hurting Animals, Destroying Property f. SELF-DESTRUCTIVE: Cuts, Hits, Kicks, Burns, Self, Bangs Head, Risk Taking g. SOCIAL SKILLS: No Friends, Prefers Younger/Older Peers, Loses Friends Quickly h. DEPRESSION: Withdrawal, Isolation, Low Energy, Hopeless, Sad, Helpless i. ACTIVITY LEVEL: Over-Active, Hyper-Active, Out of Control, Inactive, Passive j. CONFUSION: Disoriented, Forgetful, Memory Impairments, Odd Statements k. MOVEMENT PROBLEMS: Twitches, Tics, Paralysis, Seizures, Weakness, Compulsions 1. SCHOOL/WORK PERFORMANCE: Falling Grades, Fired or Expelled, Refuses to Attend m. SEXUAL: Preoccupation, Intrusive Ideas, Exposing Self, Touching Others, Role Confusion n. ABUSE/TRAUMA: Victim of Sexual/Physical/Emotional/Verbal Abuse, Accident, Injury o. SEPARATION/LOSS: Death, Divorce, Relocation p. OPPOSITIONAL/DEFIANT: Disrespectful, Defies Authority, Disobedient q. DELINQUENT: Theft, Assault, Police Involvement, CHINS r. DRUGS AND ALCOHOL: Experimentation, Abuse, Addiction, Peer Pressure s. MEDICAL PROBLEM: Chronic Illness, Terminal Illness, Medication Compliance SEPARATION AND DIVORCE: If this childs caregivers have separated or divorced any time since the childs birth, please indicate on a separate page (a) dates of separations, reunion, divorce and remarriages, as applicable; (b) the legal conditions of visitation and custody; and (c) your feeling about whether this child was successfully kept out of the middle of the divorce. FOSTER CARE AND ADOPTION: If this child is or has been in foster care, or is adopted, please indicate on a separate page (a) dates and reasons for foster care; (b) plan for return to or contact with other caregivers; and/or (c) details and history about natural parents/reasons for adoption. CONCEPTION AND DELIVERY Was this childs conception planned? YES NO How long was necessary to become pregnant?  Months What was the reaction to learning of the pregnancy? Father: Mother: Was the baby carried to term (9 months)? YES NO Birth Weight: _____ pounds and _____ ounces Birth Length: _____ inches During pregnancy, the childs natural mother did which of the following? Smoked Tobacco. Quantity: Drank Alcohol. Type/Quantity: Consumed caffeine. Type/Quantity: Was Injured or Fell Had Serious Illness/Surgery Used Prescription Drugs. Please specify ______________________ Experienced Other Major Stress. Please Specify: _______________________ Please indicate which of the following was true of delivery: Vaginal Delivery Cesarean Section V-Back Mother Had General Anesthetic Baby Experienced Fetal Distress. YES NO If YES please specify: __________________________ What were the childs APGAR scores? ______ and ______ Did mother or child experience medical complications following delivery? YES NO If YES please elaborate: Mother returned home _____ days after delivery. Child returned home _____ days after delivery INFANCY AND TODDLER YEARS (Approximately ages 0 through 2 years old) Please check in the boxes below which caregiver was primarily responsible for each of the activities listed. ACTIVITY:MOTHER:FATHER:OTHER (Please Specify)FeedingBathingDiaperingResponding to CryingPlaying Was this child breast-fed? YES NO If so, s/he was weaned at _____ months old. Did you feel that any of the childs early behaviors were odd or unusual? YES NO If so, please elaborate: Please note the approximate ages at which this child consistently was able to do each of the following: _____ Sits Alone _____ Stands Unassisted _____ Rolls Over Unassisted _____ Says First Words _____ Walks Unassisted _____ Says First Sentences _____ Sleeps Through Night _____ Full Bowel Control _____ Fears Strangers _____ Full Urine Control _____ Shared Toys with Others _____ Scribbled with a Crayon What three adjectives best describe this child during infancy and toddler years? What was the most difficult part of this childs first two years? Did the child experience any illness, injury or prolonged separations during the first two years? YES NO If YES, please elaborate: PRESCHOOL YEARS (Approximately 2 to 5 years old) Please use the table below to indicate how this child responded to others during these years: ACTIVITYHAPPYINDIFFERENTUPSETHeld by motherPlays near motherMother leaves childHeld by fatherPlays near fatherFather leaves childStranger approachesStranger hold child Please note the approximate ages at which this child consistently was able to do each of the following: ______ Tie Shoes ______ Dresses Unassisted ______ Bathes Unassisted _____ Cleans Up When Asked _____ Brushes Own Teeth _____ Began Day Care _____ Birth of Next Sibling _____ Began Preschool _____ Shares and Cooperates _____ Began Kindergarten _____ Writes Own Name _____ Reads Short Words Did this child have a favorite object (toy, animal) which seemed to comfort him or her? YES NO If YES, When did the Child give this object up? _____ years old Elementary School Years (Approximately ages 6 through 11 years old) HAS THIS CHILD ...? Please elaborate on any YES responses on the reverse of this page. had any prolonged absences from school? YES NO failed or repeated any grade? YES NO ...had psychological testing of any kind? YES NO had speech and language or audiological testing? YES NO ever been suspended or expelled from any activity? YES NO What three adjectives best describe this childs attitude toward school and learning? In elementary school, this childs ... FAVORITE SUBJECT: ______________________ BEST SUBJECT was: _______________________ WORST SUBJECT was: ___________________ In elementary school, this child wanted to be a _________________________ when s/he grows up. Family and Home Please describe this childs immediate and extended family below. In the right hand column marked ??? indicate any of the following codes that describe the individuals listed: AC Alcohol or Chemical Dependency DS Depression or Suicide Attempts PSY Psychiatric/Psychological Problems CP Chronic Physical Illness LP Learning Problems/School Failure Al Arrested, Imprisoned or Convicted MR Mental Retardation V Violent, Aggression, Dangerous P Physical illness (please specify) RELATION FULL NAME AGE LIVE WITHCHILD ???  If anyone else live in the same home with the child (examples: butler. roommate. please list here: Please list the places where this child has resided since birth. Continue on the reverse, if necessary: LOCATION BETWEEN AGES: LIVED WITH WHOM?  Medical Status Has this child ever... ... required major surgery of any kind? YES NO ... had seizures, black outs or lost time? YES NO ... lost consciousness? YES NO ... had heart or lung diseases? YES NO ....had an infectious disease? YES NO ... had a head injury? YES NO ... required hospitalization? YES NO Explain any YES responses: Does this child complain of chronic physical discomfort? YES NO Please elaborate if YES: Please list the childs current medications: MEDICATION DOSAGE FREQUENCY/DAY PRESCRIBED BY WHOM?  Relevant Contact Persons In order to provide the most comprehensive mental health services possible, it is important to gather information from a wide variety of sources. This often includes having caregivers permission to exchange information with teachers, physicians, past therapists, and others involved in the childs and familys life. Please indicate below the names and contact information for the individuals or agencies who might be able to provide further relevant information. This, however, does not allow us to contact these people. This information will simply be used to complete formal release forms which, if you choose to sign, will then allow us to contact the individuals or agencies so designated. 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